Provider Demographics
NPI:1659414530
Name:TINGUELY, MARY ANNE
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ANNE
Last Name:TINGUELY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:719 MCGRAW DR
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80526-3978
Mailing Address - Country:US
Mailing Address - Phone:970-222-8274
Mailing Address - Fax:
Practice Address - Street 1:9220 BASS LAKE RD STE 260
Practice Address - Street 2:
Practice Address - City:NEW HOPE
Practice Address - State:MN
Practice Address - Zip Code:55428-3019
Practice Address - Country:US
Practice Address - Phone:763-533-0363
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-14
Last Update Date:2019-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPT1378225100000X
CO97602251P0200X
MN92732251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME235380099Medicaid
ME022801OtherANTHEM MAINE
ME1283903OtherAETNA